أ. د حسان النعمانى

استاذ - رئيس الجامعة - جامعة سوهاج

كلية الطب

العنوان: العنوان الشخصى : ش الجمهورية بسوهاج -عنوان العمل : مبنى الادارة المركزية - الدور الثالث -جامعة سوهاج

إعجاب

Foot Compartment Syndrome

2018-10-31 02:54:39 |

Introduction

Devastating condition where an osseofascial compartment pressure rises to a level that decreases perfusion
May lead to irreversible muscle and nerve damage
May occur anywhere that skeletal muscle is surrounded by fascia, but most commonly
- leg
- forearm
- hand
- foot (details below)
- thigh
- buttock
- shoulder
- paraspinous muscles
Pathophysiology
- local trauma and soft tissue destruction> bleeding and edema > increased interstitial pressure > vascular occlusion > myoneural ischemia
Causes
- trauma
  - fractures (69% of cases)
    - 5-17% of calcaneus fractures result in compartment syndrome
  - crush injuries
  - severe ankle sprains
  - gunshot wounds
- tight casts, dressings, or external wrappings
- burns
- postischemic swelling
- bleeding disorders
- vascular injury

Anatomy

9 main compartments (controversial)
- medial
  - abductor hallucis
  - flexor hallucis brevis
- lateral
  - abductor digiti minimi
  - flexor digiti minimi brevis
- interosseous (x4)
- central (x3)
  - superficial
    - flexor digitorum brevis
  - central
    - quadratus plantae
  - deep
    - adductor hallucis
    - posterior tibial neurovascular bundle

Presentation

Symptoms
- pain out of proportion to injury
Physical exam
- pain with dorsiflexion of toes (MTPJ)
  - places intrinsic muscles on stretch
- tense swollen foot
- loss of two-point discrimination
- pulses
  - presence of pulses does not exclude diagnosis

Evaluation

Radiographs
- obtain to rule-out fracture
Compartment pressure measurements
- indications
  - polytrauma patients
  - patient not alert/unreliable
  - inconclusive physical exam findings
- relative contraindication
  - unequivocally positive clinical findings should prompt emergent operative intervention without need for compartment measurements
- technique
  - central compartment
    - base of first metatarsal
    - direct needle lateral and plantar through abductor hallucis
  - medial compartment
    - base of first metatarsal advancing 2cm into abductor hallucis
  - interosseous
    - second, third, and fourth webspaces
    - advance plantar 2cm to puncture extensor fascia
  - lateral
    - midshaft of fifth metatarsal
    - advance 1cm medial and plantar
- threshold for decompression
  - controversial, but generally considered to be
    - absolute value of 30-45 mm Hg
    - within 30 mm Hg of diastolic blood pressure (delta p)
      - intraoperatively, diastolic blood pressure may be decreased from anesthesia
        
        must compare intra-operative measurement to pre-operative diastolic pressure

Treatment

Nonoperative
- observation
  - indications
    - delta p > 30
    - exam not consistent with compartment syndrome
Operative
- emergent foot fasciotomies
  - indications
    - clinical presentation consistent with compartment syndrome
    - compartment measurements with absolute value of 30-45 mm Hg
    - compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
      - intraoperatively, diastolic blood pressure may be decreased from anesthesia
        
        must compare intra-operative measurement to pre-operative diastolic pressure

Surgical Technique

Emergent fasciotomies of all compartments
- dual dorsal incisions (gold standard)
  - approach
    - dorsal medial incision
      - medial to 2nd metatarsal
      - releases 1st and 2nd interosseous, medial, and deep central compartment
    - dorsal lateral incision
      - lateral to 4th metatarsal
      - releases 3rd and 4th interosseous, lateral, superficial and middle central compartments
  - technique
    - dorsal fascia of each interosseous compartment opened longitudinally
    - strip muscle from medial fascia in first interosseous compartment
    - split adductor compartment
    - may add medial incision for decompression of calcaneal compartment
  - post-operative
    - delayed wound closure with possible skin grafting
  - pros
    - direct access to all compartments
    - provides exposure for Chopart, Lisfranc, or tarsometatarsal fractures
  - cons
    - does not provide access for fixation of calcaneus fractures
- single medial incision
  - technique
    - single medial incision used to release all nine compartments
  - cons
    - technically challenging

Complications

Chronic pain and hypersensitivity

المرفقات

الملحقات

Operative Techniques: Foot and Ankle Sur

2018-11-01 00:40:30 Foot Compartment Syndrome

download link :http://0810fphc5.1106.y.https.www.clinicalkey.com.mplbci.ekb.eg/#!/browse/book/3-s2.0-C20120012471 OPERATIVE TECHNIQUES: FOOT AND ANKLE SURGERY SECOND EDITION ISBN: 978-0-323-48234-9 COPYRIGHT © 2018 BY ELSEVIER, إقراء المزيد

تواصل معي

العنوانالعنوان الشخصى : ش الجمهورية بسوهاج -عنوان العمل : مبنى الادارة المركزية - الدور الثالث -جامعة سوهاج
رقم الهاتف1002554984
الفاكس932332761
البريد الإلكترونيhassan.noaman@med.sohag.edu.eg

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